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2. Mortality Among Patients with Tuberculosis and Associations with HIV Status — United States, 1993–2008

Although deaths among persons with both HIV and TB disease have decreased substantially since 1993, continued efforts are critical to further reduce mortality. Persons with HIV are at increased risk for TB disease and death. To better understand the impact of HIV on the risk of death during treatment for TB disease in the U.S., researchers analyzed TB case data reported to CDC from 1993-2008; mortality analyses were restricted to data through 2006 to allow time for complete reporting. Overall, the proportion of TB patients who died during treatment declined from 18 percent in 1993 to 9 percent in 2006. Among TB patients with HIV, deaths declined from 41 percent to 20 percent, and the proportion of patients with HIV who were dead at the time of TB diagnosis declined from 7 percent to 4 percent. These declines correspond to an increase in HIV testing of TB patients and widespread availability of HIV antiretroviral therapies. Deaths did not decline among TB patients with unknown HIV status, suggesting many may have had undetected HIV. In 2008, HIV status was still unknown for 21 percent of patients; this despite recommendations stating that all TB patients should be tested for HIV. The authors note that knowledge of HIV status is important to ensure appropriate treatment for TB patients, and more must be done to improve HIV and TB screening, initiate early treatment, and prevent TB among this population.

In sub-Saharan Africa, tuberculosis (TB) is the leading cause of death among HIV-infected persons. Many TB patients do not know their HIV status and, therefore, cannot benefit from HIV care and treatment services that can reduce illness and death. The Kenya Ministry of Health has introduced a program to increase HIV services, including HIV testing, for TB patients. The data from this study show that in Kenya two such activities, HIV testing in TB clinics and cotrimoxazole prophylaxis for HIV-infected TB patients, have been successfully implemented. From 2006 to 2009, HIV testing increased from 60 percent (of 115,234 TB patients) to 88 percent (of 110,015 TB patients). In 2009, 92 percent of HIV-infected TB patients received cotrimoxazole prophylaxis to prevent opportunistic infections, but only 34 percent received potentially life-saving antiretroviral treatment along with their TB treatment. However, more work remains to ensure that HIV-infected TB patients also receive antiretroviral treatment, which is mainly provided in HIV clinics. Further efforts are needed to improve access to HIV clinical services by educating patients, addressing lack of transportation, and increasing availability of HIV services. The Centers for Disease Control and Prevention (CDC), through the President’s Emergency Plan for AIDS Relief, works closely with Ministries of Health to strengthen TB and HIV programs. The technical assistance provided to Kenya is one example of CDC’s focus on strengthening national health systems and capacities of Ministries of Health to implement sustainable, evidence-based prevention, care, and treatment services in the most cost-effective and efficient manner. These efforts have led to increased HIV testing among TB patients in Kenya, as well as many other countries in sub-Saharan Africa.

4. Racial Disparities in Smoking-Attributable Mortality and Years of Potential Life Lost — Missouri, 2003–2007

State of Missouri Department of Health and Senior Services
Jacqueline Lapine — Chief, Office of Public Information(573) 751-6062

More needs to be done to reduce smoking among all racial groups. The most effective strategies are increasing the price of tobacco, implementing smoke-free laws in workplaces and public places, running aggressive anti-tobacco media campaigns, and providing support for quitting tobacco use. In Missouri, during 2003–2007, the average annual smoking-attributable mortality rate was 18 percent higher for blacks than for whites. The relative difference in smoking-attributable mortality rates between blacks and whites was larger for men (28%) than women (11%). Smoking-attributable mortality rates for blacks were higher than for whites for cancer (26%) and circulatory diseases (53%) but lower for respiratory diseases (-32%). Overall, smoking caused 32.1% of all cancer deaths, 15.3% of all circulatory disease deaths, and 46.5% of all respiratory disease deaths in Missouri during this timeframe. While population based strategies by state tobacco control programs continued to be effective, targeted strategies for certain high risk groups might also be needed to further reduce tobacco-related disparities.